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I have soap note which turn it in score is 55 % and need to redo it based on professors recommendation.
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Mini-SOAP Note
Student’s Name: Lilit Kalashyan
Date: 02/17/2024
Age: 23 years
Date of Birth: 2000
Ethnicity: Caucasian
Gender: Female
Marital status: Single
Comment: Difficulties achieving orgasm
Chief
Complaint
(CC)
History of
Present Illness
(HPI)
**GYN
Focus**
OB/GYN
history
Sexual History
Past Medical
History (PMH)
Past Surgical
History (PSH)
Immunization
status
Medications
**birth
control**
SUBJECTIVE DATA
‘I have been having difficulties achieving orgasm during sexual intercourse’
Ms. J. is a 23-year-old female presenting with concerns regarding her sexual
health. She reports difficulties achieving orgasm during sexual intercourse.
The problem is gradual and has been ongoing for the past 2 years. No specific
aggravating or relieving factors have been identified. This causes distress in
her sexual relationship. No history of sexual trauma, dyspareunia, or changes
in libido.
Gravida/Para: G0P0. Patient reports regular menstrual cycles with no history
of dysmenorrhea or abnormal bleeding. Last menstrual period was February
5, 2024.
Patient reports being sexually active with one male partner. Patient denies
history of sexually transmitted infections. Patient is not currently using any
form of birth control. Patient identifies as heterosexual.
No history of mild or chronic medical conditions
No history of surgical operations
Up to date on all immunizations
Patient is not currently on any medications.
1
Allergies
Family History
(FH)
Social History
(SH)
No medication, food, or environmental allergies reported
Mother, alive at 48, no medical problems
Father, alive at 55, alcoholism
No siblings
Patient is single. Patient denies illicit drug use and smoking. Patient’s exercise
habits are moderate. Patient is employed as a teacher in elementary school.
Patient has completed a Bachelor’s degree in mathematics. Patient identifies as
atheist. Patient has a supportive network of friends. Patient reports moderate
stress related to work and personal relationships.
Review of
Systems
(ROS)
Constitutional
Skin
Eyes, Ears,
Nose
Throat/Mouth
Cardiovascula
r
Patient denies fever, chills, fatigue, or night sweats. Reports feeling generally
well. No recent changes in weight or appetite.
Denies history of rashes, itching, or lesions. No changes in skin color or texture
reported. Reports regular use of sunscreen
Eyes: Denies visual disturbances. Denies blurred vision, double vision, or
photophobia. Reports annual eye exams and up-to-date corrective lenses.
Ears: Denies hearing loss or tinnitus. Denies ear pain, discharge, or recurrent
infections.
Nose: Denies congestion, rhinorrhea, or nasal bleeding. Denies history of sinus
infections or allergies.
Throat/Mouth: Denies sore throat, dysphagia, or mouth ulcers. Reports regular
dental check-ups and oral hygiene practices.
Denies chest pain, palpitations, or syncope. Denies edema or claudication.
Reports regular exercise routine.
Respiratory
Denies shortness of breath, cough, or wheezing. Denies history of asthma or
chronic bronchitis. Reports annual flu vaccination.
Gastrointestin
al
Denies nausea, vomiting, abdominal pain, or changes in bowel habits. Reports
regular bowel movements and dietary habits.
Reproductive /
Genitalia /
Genitourinary
Breast/Lymph
atics
Reports difficulty achieving orgasm. No history of dyspareunia, vaginal
dryness, or abnormal vaginal discharge.
Denies breast pain, lumps, or discharge. Reports monthly breast self-exams and
annual clinical breast exams
Musculoskelet
al
Denies joint pain or stiffness. Denies history of arthritis or osteoporosis.
Reports regular exercise and stretching routines.
2
Neurological
Denies headaches, dizziness, or focal neurological deficits. Denies history of
seizures or migraines. Reports annual neurological screenings.
OBJECTIVE DATA
Physical Exam
General/Constitutional
Vital Signs
Skin
HEENT
Alert and oriented, well-developed, well-dressed, in no acute distress.
Temp: 98.6°F Pulse: 72 bpm Resp: 16 breaths per minute BP: 120/70
mmHg Ht: 5’6’’ Wt: 130 lbs BMI: 21 kg/m²
Warm and intact, no lesions
Head: Normocephalic, atraumatic.
Eyes: Pupils equal, round, and reactive to light. No nystagmus.
Ears: Tympanic membranes intact bilaterally. Normal hearing acuity.
Nose: Nasal mucosa pink and moist. No septal deviation or masses.
Throat/Mouth: Oropharynx clear, no erythema or exudates. Good
dentition.
Neck
Supple, no lymphadenopathy
Respiratory
Clear to auscultation bilaterally, no wheezes or crackles
Cardiovascular
Regular rate and rhythm, no murmurs or gallops. Capillary refill
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